What is the treatment for peripheral artery disease?

Treatment for Peripheral Artery Disease

The treatment for peripheral artery disease (PAD) should begin with optimal medical therapy combined with supervised exercise training, with revascularization reserved for those who fail conservative management or have limb-threatening ischemia. 1

Medical Therapy

Risk Factor Modification

• Smoking cessation: Critical for all PAD patients
• Blood pressure control: Target <140/90 mmHg
• Diabetes management: Optimize glycemic control
• Lipid management:
  • High-intensity statin therapy regardless of baseline LDL levels 1
  • Consider adding PCSK9 inhibitor for high-risk patients with inadequate LDL response 2
  • Icosapent ethyl 2g twice daily may be considered for high-risk patients with triglycerides >1.5 mmol/L despite statin therapy 2

Antithrombotic Therapy

• First-line therapy:

  • Antiplatelet therapy with aspirin (75-100mg daily) or clopidogrel (75mg daily) 1, 3
  • Clopidogrel is indicated to reduce the rate of MI and stroke in patients with established PAD 3

• For high-risk patients:

  • Combination of rivaroxaban (2.5mg twice daily) plus aspirin (100mg daily) should be considered for patients with high ischemic risk and non-high bleeding risk 2
  • This combination should also be considered following lower-limb revascularization in patients with non-high bleeding risk 2

Exercise Therapy

Supervised Exercise Training (SET)

• Strongly recommended as first-line treatment for symptomatic PAD 2
• Protocol:
  • Frequency: At least 3 times per week
  • Duration: Minimum 30 minutes per session
  • Program length: At least 12 weeks 1
  • Walking should be the first-line training modality 2
  • High-intensity training (77%-95% of maximal heart rate) improves walking performance 2

Home-Based Exercise Training (HBET)

• Consider when SET is unavailable or not feasible
• Should be structured and monitored (calls, logbooks, connected devices) 2
• Less effective than SET but better than no exercise program 1

Pharmacological Therapy for Claudication

• Cilostazol: 100mg twice daily for lifestyle-limiting claudication (contraindicated in heart failure) 2
• Pentoxifylline: May be considered as second-line therapy (400mg three times daily), though clinical effectiveness is marginal 2, 4

Revascularization

When to Consider Revascularization

• Indicated only after a 3-month period of optimal medical therapy and exercise with:
  • Persistent lifestyle-limiting symptoms affecting quality of life 2
  • Inadequate response to exercise/pharmacological therapy 2
  • Limb-threatening ischemia

Endovascular Approach

• Femoro-popliteal lesions: Drug-eluting treatment should be considered as first-choice strategy 2
• Iliac lesions:
  • Endovascular intervention is recommended as preferred technique for TASC type A lesions 2
  • Stenting is effective as primary therapy for common iliac artery stenosis/occlusions 2

Surgical Approach

• Consider when an autologous vein (e.g., great saphenous vein) is available in patients with low surgical risk 2
• Superior long-term patency for longer lesions compared to endovascular approaches 1

Follow-up and Surveillance

• Regular clinical assessment at least once yearly 1
• Evaluate:
  • Clinical status
  • Medication adherence
  • Symptom progression
  • Need for additional interventions

Common Pitfalls to Avoid

1. Inappropriate revascularization: Not recommended for asymptomatic PAD or solely to prevent progression to critical limb-threatening ischemia 2
2. Underutilization of exercise therapy: Often overlooked despite strong evidence
3. Primary stent placement in femoral, popliteal, or tibial arteries is not recommended 2
4. Chelation therapy is not indicated and may have harmful effects 2
5. Inadequate medical therapy: Many patients do not receive comprehensive risk factor modification

The treatment approach should follow a stepwise algorithm starting with optimal medical therapy and exercise, followed by revascularization only when conservative measures fail or for limb-threatening conditions.